This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text The Summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

Timko C., DeBenedetti A.Drug and Alcohol Dependence: 2007, 90, p. 270–279.Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Timko at ctimko@stanford.edu.

Even in a largely 12-step oriented programme, this US study showed that persistent and practical efforts can modestly strengthen 12-step group involvement after treatment and improve outcomes.

Summary Some of the data in this entry derive from an earlier report on the same study.

Compared with patients who received standard referral, patients who received intensive referral were more likely to attend and be involved with 12-step groups across the first and second six months of the follow-up period, and improved more on alcohol and drug use outcomes over the year. Specifically, across both follow-up periods, after intensive referral patients were more likely to attend at least one meeting per week (70% versus 61%), were more involved with the groups, experienced greater reductions in alcohol and drug problems, and were more likely to be abstinent from alcohol and other drugs (51% versus 41%) chart. Analysis suggested that intensive referral improved alcohol and drug use outcomes by strengthening involvement in 12-step groups and associated activities. Attendance at groups was associated with substance use outcomes, but even after attendance was accounted for, stronger involvement remained associated with better outcomes.

The authors concluded that intensive referral was associated with improved 12-step group attendance and involvement and substance use outcomes. To maximally benefit patients, they recommended that treatment providers should focus 12-step referral procedures on encouraging broad 12-step group involvement, such as reading 12-step literature, doing service at meetings, and developing an identity as a group member.

commentary This study is not the first to have shown that counselling targeted at raising 12-step attendance and involvement can have the intended effects and thereby improve substance use outcomes, but it does seem the first major study to have shown that this can be the case, even when the surrounding programme itself promoted 12-step involvement. Other studies discussed below.

While this study was concerned with the intensity of the referral procedure, US studies have shown that interpersonal style is also relevant. In one previously analysed by Findings, alcohol dependent patients admitted for inpatient detoxification were randomly allocated to one of two types of continuing care advice. The first was five minutes of highly directive advice during which patients were told they had a significant drink problem and that abstinence was very important, and were then unambiguously advised to get as involved as possible in AA/NA aftercare. The second was a one-hour session which also advised abstinence and AA attendance, but in the tradition of motivational interviewing, avoided being explicitly directive and asked patients to choose their own aftercare preferences. Overall there was no difference in later drinking or heavy drinking. However, among patients less committed to 12-step groups, the motivational interviews led to better drinking outcomes, while the more committed did worse. In contrast, patients already set on attending AA did better with brief direct advice, worse after the motivational interview. A later study involved patients who had responded to ads to join a study of skills-based alcohol therapy, most of whom had no prior experience with AA. It showed that both intensity and style have an impact. The basic therapy included a few minutes during which patients were instructed to attend AA and those who did so were encouraged to continue. In the same manner but much more extensively, other patients were instructed to attend and over a third of therapy time was devoted to discussing and encouraging involvement in AA. This had the intended effect of intensifying post-treatment AA involvement and (thereby it seemed) somewhat increasing abstinence rates, though alcohol-related problems or heavy drinking days were unaffected. In contrast a motivational-style attempt to encourage AA involvement (the message was "ultimately it is up to you" and cons as well as pros were rehearsed) which was also relatively extensive had no more impact either on involvement or drinking than the few minutes incorporated in the basic therapy. It is important to remember that these studies were conducted in the US context, where 12-step groups are so much 'part of the scenery' that (as in the Project MATCH alcohol treatment trial) directive advice to attend them may not feel directive at all to the patients. In Britain the results might be quite different, though the principle that some styles of communicating will suit some people but not others, and in particular that people already committed to 12-step involvement will react best to direct and congruent advice, is likely to be universal.

In the featured study, few patients were excluded, relatively few refused to participate, and follow-up rates were high, suggesting that given the same interventions, the results would be applicable across the clinic’s entire caseload of US ex-military personnel. Nevertheless, for several reasons the results might not be replicated in routine practice. Intensive referral counsellors were trained and supervised by the research team based on audio-taped sessions, and continued to be monitored through tapes and through post-session counsellor and patient checklists. What this was compared to was intended to approximate standard referral procedures at such clinics, but was also closely controlled via a standardised script to avoid overlap with intensive referral. The intention (and the result) was to limit the discretion of the counsellors and to create a sharp divide between the two referral options. As a result, the study illustrates what happens when intensive referral is implemented to perhaps an unusually high degree of consistency, and comparator counsellors are fettered from exercising discretion depending on the needs and willingness of the patient to engage with post-treatment 12-step groups. The study shows that, in these circumstances, intensive referral does make a difference, but not necessarily that it would if comparison counsellors were allowed to exercise discretion, nor that it would if intensive referral were routinely implemented. Neither do the findings necessarily support across-the-board intensive referral. This was least effective for the quarter of patients who had previously attended 12-step groups the most, presumably because many would have continued to attend regardless.

Given these circumstances, what requires explanation is not just why intensive referral had the impacts it did, but why it did not have greater impacts. It involved (unless the patient had already started attending the groups) the counsellor calling a mutual aid group volunteer during each of three counselling sessions to arrange, then and there, for them to meet up before going to a meeting together. The comparison merely involved handing over a list of meetings and encouraging attendance. Yet in the first six months there were no statistically significant differences in attendance rates. However, during that period intensive referral patients were somewhat more deeply involved in 12-step activities. Greater involvement might explain why over the entire 12 months slightly more of these patients attended the groups, and why in the last six months of the follow up they attended on average slightly more meetings (46 v. 37). Modest as it was, this degree of enhanced involvement nevertheless resulted in somewhat higher abstinence rates and steeper reductions in substance misuse problems.

The context of the study may explain why neither involvement nor outcomes were greatly affected by intensive referral. Virtually all the patients were already familiar with 12-step groups and the core treatment programme was in any event infused with a 12-step orientation. Three sessions of intensive referral were perhaps merely the icing on the cake, most patients having already made up their minds whether to get involved in the groups based on their previous experiences and daily activities at the clinic. How far then the results might generalise to countries like the UK with less pervasive 12–step traditions is unclear. It could be that intensive referral would actually have a greater impact, a speculation supported by its being most effective with the less frequent prior attendees. It might however have to be applied in a more discriminating fashion to avoid alienating patients set against this form of continuing support. On the other hand, persistent advocacy of 12-step involvement might be both inappropriate and ineffective in treatment programmes which are not based on 12-step philosophy, including many UK programmes.

We know from the NTORS study in England that (mostly heroin-addicted) patients who regularly attend 12-step groups after residential/inpatient treatment are much more likely to sustain abstinence from alcohol and opiates. Whether this was the cause or the result of their abstinence, or both were a reflection of some other attribute, is unclear. In NTORS, over half the services actively encouraged 12-step group attendance after treatment, but unless patients had already attended such groups, they were
very unlikely
For example, just 8% in the last three months of the one-year follow-up period.
to do so after treatment ended. In Britain, where experience with 12-step groups cannot be assumed, in-treatment 'tasters' of what the groups are like may be needed, as well as sensitively applied active referral.

Thanks for their comments on this entry in draft to Christine Timko of the Veterans Affairs Health Care System in California, USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.